Causes and outcomes of hospitalization in Lewy body dementia: A retrospective cohort study

https://doi.org/10.1016/j.parkreldis.2019.03.014Get rights and content

Highlights

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    Neuropsychiatric symptoms were the most common admission reason for people with LBD

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    Delirium complicated half of hospitalizations of individuals with LBD

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    Antipsychotics were administered during 38% of hospitalizations of people with LBD

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    Non-quetiapine/clozapine antipsychotic use was associated with worse outcomes

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    33% of encounters resulted in higher levels of care; 15% ended in hospice or death

Abstract

Introduction

Understanding hospitalization in Lewy body dementia (LBD) is a known knowledge gap. We aimed to identify common causes, medication profiles, complications, and outcomes of hospitalization in LBD.

Methods

A retrospective cohort study investigated details of academic medical center hospitalizations over a two-year period for patients with LBD. Data collected included demographics, home medications, pre-hospital living status, reason for admission, admission service, inpatient medications, complications, and discharge status. Non-parametric statistics assessed associations between variables and length of stay. Odds of a change in living situation based on admission variables was calculated.

Results

The study included 178 hospitalizations (117 individuals). Neuropsychiatric symptoms were the most common admission reason (40%), followed by falls (24%) and infection (23%). Patients were usually admitted to medicine services; neurology or psychiatric consultations occurred less than 40% of the time. Antipsychotics were administered during 38% of hospitalizations. Use of antipsychotics other than quetiapine or clozapine was associated with longer length of stay and increased odds of discharge to a higher level of care. One-third of hospitalizations resulted in transition to a higher level of care; 15% ended in hospice care or death.

Conclusion

The most common reasons for hospitalization in LBD are potentially modifiable. Opportunities for improved care include increased involvement of neurological and psychiatric services, delirium prevention strategies, and reduced antipsychotic use. Clinicians should counsel patients and families that hospitalizations in LBD can be associated with end of life. Research is needed to identify strategies to prevent hospitalization and optimal standards for inpatient care.

Funding

Lewy body dementia research at the University of Florida is supported by the University of Florida Dorothy Mangurian Headquarters for Lewy Body Dementia and the Raymond E. Kassar Research Fund for Lewy Body Dementia.

Introduction

Lewy body dementia (LBD) – the second most common neurodegenerative dementia following Alzheimer disease (AD) – consists of dementia with Lewy bodies and Parkinson disease (PD) dementia. Lack of data regarding hospitalization is a known knowledge gap [1]. Emergency room visits are common: in a survey of caregivers of individuals with LBD, 64% reported a crisis in the prior year and they sought help in a hospital emergency room 73% of the time [2].

Individuals with LBD, frontotemporal dementia, and unspecified dementia are at a higher risk of hospitalization than individuals with AD, vascular dementia, or mixed dementia, likely because neuropsychiatric symptoms are the main predictor of dementia hospital admissions [3]. Hospital admission rates are significantly higher for individuals with dementia with Lewy bodies compared to AD and a catchment population [4]. Individuals with dementia with Lewy bodies have longer hospital stays than those with AD [[4], [5], [6]] and overall higher costs of care [4,7]. In one study, the most common reason for admission for individuals with “parkinsonism-related dementia” was acute delirium (41%), followed by pneumonia (20%), stroke (19%), urinary tract infection (UTI) (7%), and fall-related hip fracture (3%) [6]. In another study, the most common hospital discharge diagnoses for individuals with dementia with Lewy bodies were infections (23%), falls (7%), circulatory illness (7%), dementia (6%), and senility/disorientation (5%) [4].

While little is known regarding hospital outcomes in LBD, hospitalization in PD is a known source of worsened function [8]. Hospitalization of individuals with AD is associated with increased risks of death and institutionalization, with hospital delirium associated with even higher risks of death, institutionalization, and cognitive decline [9]. Multiple studies show that individuals with AD experiencing delirium – often in the context of hospitalization – subsequently have faster cognitive progression [[9], [10], [11]] beyond what can be attributed to the pathology itself [12]. Given that over 40% of hospitalized individuals with dementia receive antipsychotics [13] and the morbidity and mortality associated with antipsychotic use in LBD [14,15], occurrence of hospital delirium in LBD likely carries additional risks of antipsychotic-induced complications.

To address knowledge gaps regarding LBD and hospitalization, we performed a retrospective cohort study to identify common causes, complications, medication profiles, and outcomes of hospitalization for individuals with LBD.

Section snippets

Study design

A retrospective cohort study investigated the causes, experiences, and outcomes of individuals with LBD hospitalized at an academic medical center over a two-year period (1/1/2014–12/31/2015). After institutional review board approval for the chart review (IRB201600391), an honest broker queried records for any hospitalization in the 2-year period including a diagnosis code for LBD (ICD-9 331.82, ICD-10 G31.83) in the admitting diagnoses or on the inpatient problem list.

During chart review,

Demographic and clinical characteristics of participants

The search identified 178 hospitalizations meeting criteria representing 117 individual patients (Table 1). No record demonstrated evidence of a parkinsonism other than LBD. Of the 178 hospitalizations, 125 included diagnosis codes for Parkinson's disease (ICD-9 332.0 or ICD-10 G20) in addition to the codes used to identify individuals with LBD (ICD-9 331.82, ICD-10 G31.83). Eighty-one individuals had a single admission in the 2-year period and 36 individuals had multiple admissions (Table 1).

Discussion

This retrospective cohort study identified that hallucinations and confusion were the most common reasons for hospitalization for individuals with LBD, followed by falls and infection. Most patients (88%) were hospitalized on inpatient teams other than neurology and did not receive neurology or psychiatry consultations. Antipsychotic medications were administered during 38% of hospitalizations and these were new prescriptions or increased doses in 19% of hospitalizations. While quetiapine was

Funding sources

Lewy body dementia research at the University of Florida is supported by the University of Florida Dorothy Mangurian Headquarters for Lewy Body Dementia and the Raymond E. Kassar Research Fund for Lewy Body Dementia.

Author roles

CCS: Acquisition of data, analysis and interpretation of data, drafting and revising the article, final approval; AB: acquisition of data, analysis and interpretation of data, drafting and revising the article, final approval; EHM: analysis and interpretation of data, revising

References (30)

  • C. Mueller et al.

    The prognosis of dementia with Lewy bodies

    Lancet Neurol.

    (2017)
  • J.E. Galvin et al.

    Lewy body dementia: caregiver burden and unmet needs

    Alzheimer Dis. Assoc. Disord.

    (2010)
  • T.C. Russ et al.

    Prediction of general hospital admission in people with dementia: cohort study

    Br. J. Psychiatry

    (2015)
  • C. Mueller et al.

    Hospitalization in people with dementia with Lewy bodies: frequency, duration, and cost implications

    Alzheimers Dement. (Amst.)

    (2017)
  • D.L. Murman et al.

    The impact of parkinsonism on costs of care in patients with AD and dementia with Lewy bodies

    Neurology

    (2003)
  • C.C. Chang et al.

    The Impact of admission diagnosis on recurrent or frequent hospitalizations in 3 dementia subtypes: a hospital-based cohort in Taiwan with 4 Years longitudinal follow-ups

    Medicine (Baltim.)

    (2015)
  • F. Boström et al.

    Patients with Lewy body dementia use more resources than those with Alzheimer's disease

    Int. J. Geriat. Psychiat.

    (2007)
  • O.H. Gerlach et al.

    Motor outcomes during hospitalization in Parkinson's disease patients: a prospective study

    Parkinsonism Relat. Disord.

    (2013)
  • T.G. Fong et al.

    Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease

    Ann. Intern. Med.

    (2012)
  • T.G. Fong et al.

    Delirium accelerates cognitive decline in Alzheimer disease

    Neurology

    (2009)
  • M.F. Weiner

    Impact of delirium on the course of Alzheimer disease

    Arch. Neurol.

    (2012)
  • D.H. Davis et al.

    Epidemiological Clinicopathological Studies in Europe (EClipSE) Collaborative Members, Association of delirium with cognitive decline in late life: a neuropathologic study of 3 population-based cohort studies

    JAMA Psychiatry

    (2017)
  • P. Gallagher et al.

    Antipsychotic prescription amongst hospitalized patients with dementia

    QJM

    (2016)
  • I.G. McKeith et al.

    Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium

    Neurology

    (2017)
  • D. Weintraub et al.

    Antipsychotic use and mortality risk in Parkinson's disease

    JAMA Neurol

    (2016)
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